IMPORTANCEAppendectomy remains the standard of care for uncomplicated acute appendicitis despite several randomized clinical trials pointing to the safety and efficacy of nonoperative management of this disease. A meta-analysis of randomized clinical trials may contribute to the body of evidence and help surgeons select which patients may benefit from surgical and nonsurgical treatment.OBJECTIVE To assess the efficacy and safety of nonoperative management vs appendectomy for acute uncomplicated appendicitis.DATA SOURCES A systematic review was conducted using indexed sources (Embase and PubMed) to search for published randomized clinical trials in English comparing nonoperative management with appendectomy in adult patients presenting with uncomplicated acute appendicitis. To increase sensitivity, no limits were set for outcomes reported, sex, or year of publication. All nonrandomized or quasi-randomized trials were excluded, and validated primers were used.STUDY SELECTION Among 1504 studies imported for screening, 805 were duplicates, and 595 were excluded for irrelevancy. A further 96 were excluded after full-text review, mainly owing to wrong study design or inclusion of pediatric populations. Eight studies met the inclusion criteria and were selected for the meta-analysis. DATA EXTRACTION AND SYNTHESISMeta-extraction was conducted with independent extraction by multiple reviewers using the Covidence platform for systematic reviews and in accordance with PRISMA guidelines. Data were pooled by a random-effects model. MAIN OUTCOMES AND MEASURESTreatment success and major adverse effects at 30 days' follow-up. RESULTSThe main outcome (treatment success proportion at 30 days of follow-up) was not significantly different in the operative and nonoperative management cohorts (risk ratio [RR], 0.85; 95% CI, 0.66-1.11). Likewise, the percentage of major adverse effects was similar in both cohorts (RR, 0.72; 95% CI, 0.29-1.79). However, in the nonoperative management group, length of stay was significantly longer (RR, 1.48; 95% CI, 1.26-1.70), and a median cumulative incidence of 18% of recurrent appendicitis was observed.CONCLUSIONS AND RELEVANCE These results point to the general safety and efficacy of nonoperative management of uncomplicated acute appendicitis. However, this strategy may be associated with an increase in duration of hospital stay and a higher rate of recurrent appendicitis. This meta-analysis may help inform decision-making in nonoperative management of uncomplicated acute appendicitis.
Background Evidence regarding the effects of plastic bag use for appendix removal during minimally invasive appendectomy remains scarce and conflicting. Objective This study aimed to analyze the effects of plastic bag use during minimally invasive appendectomy on preoperative infection risk, morbidity and mortality. Design This retrospective analysis of the prospective National Surgical Quality Improvement Program (NSQIP) cohort program. Setting This study included data from the NSQIP database between the years of 2016 and 2019. Patient Adult patients undergoing minimally invasive (laparoscopic or robotic) without unplanned conversion to open surgery. Intervention Use of plastic bag for specimen removal during appendectomy. Main Outcome Measures Risk ratios for the incidence of superficial surgical site infection, intra-abdominal abscess, overall medical morbidity, and overall mortality. Results There were 43 783 cases of minimally invasive appendectomy in the NSQIP database between the years of 2016 and 2019. Among those who reported information regarding use of plastic bag, 28 589 (91.87%) reported use of plastic bag for specimen removal. Use of plastic bag was associated with a significant decrease in superficial surgical site infection (RR .39 (95% CI: .31-.49), P < .001), and in the risk of postoperative intra-abdominal abscess (RR: 0.66 (.57-.77), P < .001)). We also observed a robust reduction in overall medical-related morbidity and overall mortality, even after adjusting for multiple confounders. Limitations Observational nature of the study cannot exclude residual bias. Also, there was a significant rate of missing values for plastic bag use, which may bias results. Conclusions In this global prospective cohort using NSQIP database, use of plastic bag for appendix removal during minimally invasive appendectomy was associated with a significant improvement in surgical related outcomes and reduction in morbidity and overall mortality.
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